Sleep Disturbances in Chronic Pain: Neurobiology, Assessment, and Treatment in Physical Therapist Practice

Association between C-reactive protein and chronic pain in US adults: A nationwide cross-sectional study

BACKGROUND

Chronic pain has emerged as a significant global public health concern. Hence, it is imperative to acquire a more comprehensive comprehension of these characteristics in the adult population of the United States in order to facilitate the development of effective interventions. The objective of this study is to ascertain the prevalence of chronic pain among people in the United States and investigate its association with C-reactive protein (CRP) levels.

METHODS

The present study employed a cross-sectional design and utilized data from three cycles of the National Health and Nutrition Examination Survey (NHANES). The study aimed to investigate the relationship between chronic pain status, CRP levels, and potential confounding factors. The study incorporated individuals who successfully fulfilled chronic questionnaires and had CRP assays. Weighted univariate and multivariate logistic regression analyses were performed to examine the correlation between chronic pain and CRP levels. To explore the non-linear relationship, weighted restricted cubic spline (RCS) with three knots coupled with a weighted logistic regression model to assess the dose-response relationship between CRP (continuous variables) and chronic pain.

RESULTS

A total of 10,680 (Weighted 250,814,660.8) adult participants with complete information were included in the analysis and 2612 (Weighted 67978784.88, 27.1%) subjects met the definition of chronic pain. Compared with participants without chronic pain, those with chronic pain had a higher CRP level (P < 0.001). The results of the multivariable adjusted logistic regression model suggested that the highest CRP quartile (CRP >  0.52 mg/dL) was associated with a 32% increase in the risk of chronic pain compared with the lowest CRP quartile (CRP ≤  0.09 mg/dL). The RCS result showed that the OR of chronic pain and CRP displayed a linear relationship (P = 0.027, Non-linear P = 0.541).

CONCLUSIONS

The study found a significant correlation between CRP levels and the presence of chronic pain among people in the United States. Individuals exhibiting elevated levels of CRP demonstrated a heightened propensity for experiencing chronic pain in comparison to individuals with lower CRP levels. Additional investigation is necessary to explore the presence of a causal association between the two variables, as well as the potential underlying mechanisms.

An interdisciplinary virtual group program addressing the FINER points of chronic pain management: An exploratory analysis of functional outcomes

OBJECTIVES

Chronic pain is multifactorial and has large social and economic costs. Comprehensive pain management through an interdisciplinary approach addressing the biopsychosocial model of pain is beneficial. The purpose of this study was to assess the feasibility and functional outcomes following participation in the 8-week virtual interdisciplinary Functional Integrative Restoration (FINER) program.

DESIGN

Cohort study.

SETTING

Virtual platform (Zoom) utilized by participants and clinicians within a large academic institution.

SUBJECTS

44 individuals with chronic pain meeting study criteria who participated in the virtual FINER program from September 2021 to April 2023 were included in final analysis.

METHODS

Participants attended twice weekly seminars and group sessions focused on pain education, lifestyle medicine, integrative medicine, and psychological therapies virtually and completed pre- and post-program surveys. Outcomes included the Pain Catastrophizing Scale (PCS), Tampa Scale of Kinesiophobia (TSK), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). Qualitative feedback was also obtained.

RESULTS

From September 2021 to April 2023, 44 adult FINER participants with chronic low back and/or neck pain completed pre- and post-intervention surveys. We observed significant improvements in PCS, TSK, and various domains of the PROMIS-29, including pain interference, participation, physical function, and sleep, with modest effect sizes.

CONCLUSIONS

The FINER program reduced self-reported functional outcomes related to the participants' chronic pain. Positive qualitative feedback from FINER participants suggested mental and physical health benefits. Future investigation will include a larger cohort and will deploy active (patient-reported outcomes) and passive (mobility and sociability) digital measures to further characterize functional changes.

The contribution of clock genes BMAL1 and PER2 in osteoarthritis-associated pain

Joint pain is the primary symptom of osteoarthritis (OA) and the main motivator for patients to seek medical care. OA-related pain significantly restricts joint function and diminishes quality of life. Despite the availability of various pain-relieving medications for OA, current treatment strategies often fall short in delivering adequate pain relief. Furthermore, long-term use of pain medications for OA management is frequently linked with notable side effects and toxicities, suggesting the need to explore new potential targets to treat pain in OA patients. In this context, clock genes, particularly brain and muscle aryl hydrocarbon receptor nuclear translocator-like 1 (BMAL1) and period circadian protein homolog 2 (PER2), known for their role in circadian rhythms, represent promising opportunities for pharmacological interventions due to their involvement in both the development and maintenance of OA pain. While BMAL1 and PER2 have been extensively studied in neuropathic and inflammatory pain, their specific contributions to OA pain remain less clear, demanding further investigation. This narrative review aims to synthesize the relationship between OA pain and the BMAL1 and PER2 signaling pathways, ultimately exploring the potential therapeutic role of clock genes in addressing this challenging condition.

Comparative analysis of chronic neuropathic pain and pain assessment in companion animals and humans

Chronic neuropathic pain is underdiagnosed in companion animals. This paper will review the definition of pain and how classification and grading of neuropathic pain can be applied from human to veterinary medicine to increase the recognition of and the confidence in a neuropathic pain diagnosis. The mechanisms of nociception and the pathophysiology of the sensory systems that underlie the transition to chronic pain are described. Potential future methods for diagnosis and treatment of neuropathic pain in veterinary medicine are considered, utilizing the theoretical framework of pain behavior from humans and rodents. By discussing the current state of pain diagnosis in companion animals and increasing the recognition of chronic neuropathic pain, the goal is to increase understanding of chronic neuropathic pain in daily clinical practice and to aid the development of methods to diagnose and treat neuropathic pain.

Association Between Objective Sleep and Clinical Outcomes in Older Adults With Low Back Pain Receiving Physical Therapy Care: A Secondary Analysis of a Responsiveness Study

BACKGROUND/OBJECTIVES

Sleep seems to be associated with worse low back pain (LBP) outcomes in older adults; however, studies investigating the association of objective sleep with future changes in LBP outcomes are lacking. The objectives of this study are as follows: (a) to investigate the association between objectively measured sleep with changes in clinical outcomes in older adults with LBP receiving physical therapy care and (b) to examine the cross-sectional association between sleep and pain catastrophizing.

METHODS

This was a prospective cohort study. We recruited older adults (≥60 years old) with chronic LBP undergoing physical therapy treatment. At baseline, we assessed participants' sleep (actigraphy for 10-14 days), pain intensity, disability, pain catastrophizing, and covariates. After 8 weeks, we reassessed pain intensity, disability, and self-perceived recovery. We ran linear regression models and Spearman coefficient tests.

RESULTS

Fifty-eight participants were included, and 51 completed follow-up assessments (60.8% women; mean age 70.1 ± 5.6 years). We found no associations between sleep quantity and efficiency with changes in pain intensity, disability, and self-perceived recovery after 8 weeks of physical therapy care. We found a correlation between sleep fragmentation and pain catastrophizing (r = .30; 95% confidence interval: [.03, .54]).

CONCLUSION

Objective sleep quantity and efficiency may not be associated with changes in LBP outcomes after physical therapy care in older adults. Among the sleep domains evaluated, sleep fragmentation may be the sleep domain with the strongest association with pain catastrophizing. Significance/Implications: Objectively measured sleep might not be a prognostic factor for LBP improvement in older adults. Future studies should explore the association between sleep fragmentation and pain catastrophizing.

Factors related to opioid misuse among patients undergoing elective surgery in Poland

In many countries, the consumption of illicit opioids is rising, becoming a major public health issue called the "opioid crisis". Many reasons contribute to this phenomenon. One of them is opioid misuse, defined as the use of legally prescribed opioids for a purpose different than pain treatment. This matter has not been well studied in Poland, where the opioid crisis has not been identified so far. This study was conducted among patients admitted for elective surgery with opioid-based postoperative pain treatment. The frequency of opioid misuse was found to be 10.8% in a sample comprising 92 patients. The group of individuals with potential opioid use disorder had a more frequent history of inadequately controlled postoperative pain compared to the group of non-misusers (p = 0.023). Furthermore, this group asked to receive additional pain treatment almost six times more often than the control group (p < 0.000). Also, patients declaring opioid misuse reported substantial differences concerning their knowledge and opinions about pain treatment and opioid analgesics: supporting the administration of opioids for pain when needed, finding opioids less harmful, and supporting messages that opioids are safe, effective, well-tolerated, easy to cutoff more often than control. There is an urgent need for the education of patients to avoid the spreading of the opioid crisis.

Cognitive behavioral therapy for insomnia in people with chronic musculoskeletal pain. A systematic review and dose-response meta-analysis

The aims were (i) to determine the effects of Cognitive behavioral therapy for insomnia (CBT-I) on sleep disturbances, pain intensity and disability in patients with chronic musculoskeletal pain (CMP), and (ii) to determine the dose-response association between CBT-I dose (total minutes) and improvements in sleep disorders, pain intensity and disability in patients with CMP. A comprehensive search was conducted in PubMed/MEDLINE, Web of Science, CINAHL, and SCOPUS until December 17, 2023. Randomized clinical trials (RCTs) using CBT-I without co-interventions in people with CMP and sleep disorders were eligible. Two reviewers independently extracted data and assessed risk of bias and certainty of the evidence. A random effects meta-analysis was applied to determine the effects on the variables of interest. The dose-response association was assessed using a restricted cubic spline model. Eleven RCTs (n = 1801 participants) were included. We found a significant effect in favor of CBT-I for insomnia (SMD: -1.34; 95%CI: -2.12 to -0.56), with a peak effect size at 450 min of CBT-I (-1.65, 95%CI: -1.89 to -1.40). A non-significant effect was found for pain intensity. A meta-analysis of disability was not possible due to the lack of data. This review found benefits of CBT-I for insomnia compared to control interventions, with a large effect size. In addition, it was estimated that a 250-min dose of CBT-I had a large effect on reducing insomnia and that the peak effect was reached at 450 min. These novel findings may guide clinicians in optimizing the use of CBT-I in people with CMP and insomnia.

Potential vicious cycle between postoperative pain and sleep disorders: A bibliometric analysis

Background

Surgical pain affects postoperative sleep quality, and they jointly form a vicious cycle of mutual influence. The cycle of postoperative pain and sleep disorders could lead to delirium, cardiovascular disease, and hyperalgesia, which significantly affect patients' postoperative recovery. Thus, exploring this phenomenon is of great importance for surgical patients, and warrants further investigation.

Objective

By employing bibliometric methods, this study systematically analyzes the publications on postoperative pain-sleep disorders, identifies research trends and field dynamics, and ultimately provides insights for further progress in this research area.

Methods

In this study, we searched the Web of Science database for studies on postoperative pain and sleep disorders from 2013 to 2023, and analyzed the number of publications, journals, authors, institutions, country regions, and keywords by utilizing CiteSpace, VOSviewer, and Bibliometrix.

Results

The 1894 retrieved publications showed a trend of increasing number of publications and correlations between postoperative pain and sleep disorders from 2013 to 2023. The top countries for publications included the USA, China, etc., establishing a global collaborative network centered around the USA, China, and Europe. The top institutions for publications included University of California System, Harvard University, etc. The top authors include Christine Miaskowski, Steven M. Paul, Qiuling Shi, etc. These publications involved multiple disciplines including surgery, neurology, and anesthesiology, and various research funds including NIH, HHS, NSFC, etc. The top journals for publications included the European Archives of Oto-Rhino-Laryngology, etc. Keywords that appear most frequently in this field include "pain", "surgery", "quality of life", "sleep", "depression", and "outcomes". The thematic map indicated that the hot topics in this area include obstructive sleep apnea, tonsillectomy, children, pain, quality of life, and sleep. The undeveloped topics with research potential included postoperative pain, analgesia and dexmedetomidine, breast cancer, fatigue, and lung cancer.

Conclusion

The increased number of publications and correlations between postoperative pain and sleep disorders, and the collaborative network across the USA, China, and Europe indicate a growing global interest in this area. This study also provides valuable insights into the trend of hot topics and frontiers and shows that this is an evolving and dynamic research area.

Insomnia among patients with chronic pain: A retrospective study

Insomnia can coexist with chronic pain and is a major cause of rapidly increasing medical expenses. However, insomnia has not been fully evaluated in patients with chronic pain. This retrospective study aimed to identify the risk factors for insomnia in patients with chronic non-cancer pain. A total of 301 patients with chronic non-cancer pain were enrolled. Patients with the Athens insomnia scale scores ≥ 6 and < 6 were classified into insomnia (+) and insomnia (-) groups, respectively. All patients completed self-report questionnaires as part of their chronic pain treatment approach. Univariate and multivariate analyses were performed to predict insomnia. We found that 219 of 301 (72.8%) patients met the AIS criteria for insomnia. Significant differences were depicted between patients with and without insomnia in terms of body mass index, numeric rating scale, pain catastrophizing scale, hospital anxiety, and depression scale (HADS), pain disability assessment scale, EuroQol 5 dimension (EQ5D), and pain self-efficacy questionnaire. Multiple regression analysis identified the numeric rating scale, HADS, and EQ5D scores as factors related to insomnia in patients with chronic non-cancer pain. Anxiety, depression, and disability were associated with a greater tendency toward insomnia. HADS and EQ5D scores are useful screening tools for preventing insomnia in patients with chronic non-cancer pain.

Cognitive Behavioral Therapy for Insomnia in Pain Management for Nonspecific Chronic Spinal Pain: A Randomized Clinical Trial

Importance

Insomnia is highly prevalent in patients with nonspecific chronic spinal pain (nCSP). Given the close interaction between insomnia and pain, targeting sleep problems during therapy could improve treatment outcomes.

Objective

To evaluate the effectiveness of cognitive behavioral therapy for insomnia (CBTi) integrated in best-evidence pain management (BEPM) vs BEPM only in patients with nCSP and insomnia.

Design, Setting, and Participants

A multicenter randomized clinical trial with 1-year follow-up was conducted between April 10, 2018, and April 30, 2022. Data and statistical analysis were performed between May 1, 2022, and April 24, 2023. Patients with nCSP and insomnia were evaluated using self-report and at-home polysomnography, to exclude underlying sleep pathologic factors. Participants were treated at the University Hospital Brussels or University Hospital Ghent, Belgium. Intention-to-treat analysis was performed.

Interventions

Participants were randomized to either CBTi-BEPM or BEPM only. Both groups received 18 treatment sessions over 14 weeks. The CBTi-BEPM treatment included 6 CBTi sessions and 12 BEPM sessions. The BEPM treatment included pain neuroscience education (3 sessions) and exercise therapy (9 sessions in the CBTi-BEPM group, 15 sessions in the BEPM-only group).

Main Outcomes and Measures

The primary outcome was change in mean pain intensity (assessed with Brief Pain Inventory [BPI]) at 12 months after the intervention. Exploratory secondary outcomes included several pain- and sleep-related outcomes. Blinded outcome assessment took place at baseline, posttreatment, and at 3-, 6-, and 12-month follow-up.

Results

A total of 123 patients (mean [SD] age, 40.2 [11.18] years; 84 women [68.3%]) were included in the trial. In 99 participants (80.5%) with 12-month BPI data, the mean pain intensity at 12 months decreased by 1.976 points (reduction of 40%) in the CBTi-BEPM group and 1.006 points (reduction of 24%) points in the BEPM-only group. At 12 months, there was no significant difference in pain intensity change between groups (mean group difference, 0.970 points; 95% CI, -0.051 to 1.992; Cohen d, 2.665). Treatment with CBTi-BEPM resulted in a response for BPI average pain with a number needed to treat (NNT) of 4 observed during 12 months. On a preliminary basis, CBTi-BEPM was, consistently over time and analyses, more effective than BEPM only for improving insomnia severity (Cohen d, 4.319-8.961; NNT for response ranging from 2 to 4, and NNT for remission ranging from 5 to 12), sleep quality (Cohen d, 3.654-6.066), beliefs about sleep (Cohen d, 5.324-6.657), depressive symptoms (Cohen d, 2.935-3.361), and physical fatigue (Cohen d, 2.818-3.770). No serious adverse effects were reported.

Conclusions and Relevance

In this randomized clinical trial, adding CBTi to BEPM did not further improve pain intensity reduction for patients with nCSP and comorbid insomnia more than BEPM alone. Yet, as CBTi-BEPM led to significant and clinically important changes in insomnia severity and sleep quality, CBTi integrated in BEPM should be considered in the treatment of patients with nCSP and comorbid insomnia. Further research can investigate the patient characteristics that moderate the response to CBTi-BEPM in terms of pain-related outcomes, as understanding of these moderators may be of utmost clinical importance.

Trial Registration

Clinical Trials.gov Identifier: NCT03482856.

Psychosocial Factors, Sleep, and Central Pain Processing for Making a Prognosis About Recovery of Pain, Function, and Quality of Life After Rotator Cuff Repair: An Exploratory Longitudinal Study

OBJECTIVE: To explore modifiable psychosocial factors, sleep-related variables, indices of central pain processing and patients' characteristics as potential prognostic factors for pain, shoulder function, and quality of life (QoL) 1 year after rotator cuff repair. DESIGN: This observational longitudinal study included 142 patients who were undergoing rotator cuff repair. All measures took place pre-rotator cuff repair (T0), and 12 weeks (T1) and 12 months (T2) after rotator cuff repair. METHODS: Mixed-effects linear regression modeled relationships between the Western Ontario Rotator Cuff Index (WORC, model A), the Subjective Shoulder Value (SSV, model B), and EuroQol's EQ-5D-5L for QoL (model C), and potential prognostic factors over time. Factors included psychosocial variables, sleep-related indices, and proxies of central pain processing. Patients' age, sex, and body mass index complemented the analyses. RESULTS: At follow-up (T2), data from 124 participants were available for analysis. Five prognostic factors were identified for the 1-year outcome. Better expectations for symptom reduction (P<.0001, -1.4 mm) and an increase in Douleur Neuropathique 4 score (P = .0481, -0.9 mm) affected the evolution of WORC over time (model A). An increase in injury perception subscale consequence (P = .0035, 0.04%) influenced the SSV trajectory (model B). In addition, when sleep quality (P = .0011, -0.13%) and sleep efficiency (P = .0002, 0.005%) improved, the EQ-5D-5L slope was affected (model C). CONCLUSION: Addressing cognitions, pain mechanisms and sleep behavior prior to rotator cuff repair can identify people who are at risk of a poor outcome after surgery. J Orthop Sports Phys Ther 2024;54(8):530-540. Epub 4 July 2024. doi:10.2519/jospt.2024.12398.

Pain, obesity, adenosine salvage disruption, and smoking behavior mediate the effect of gut microbiota on sleep disorders: results from network Mendelian randomization and 16S rDNA sequencing

Objectives

The objective of this study is to investigate the indirect causalities between gut microbiota and sleep disorders.

Methods

In stage 1, we utilized 196 gut microbiota as the exposure factor and conducted a two-sample univariable Mendelian randomization (MR) analysis on five sleep disorders: insomnia, excessive daytime sleepiness (EDS), sleep-wake rhythm disorders (SWRD), obstructive sleep apnea (OSA), and isolated REM sleep behavior disorder (iRBD). In stage 2, we validated the MR findings by comparing fecal microbiota abundance between patients and healthy controls through 16S rDNA sequencing. In stage 3, we explored the indirect pathways by which the microbiota affects sleep, using 205 gut microbiota metabolic pathways and 9 common risk factors for sleep disorders as candidate mediators in a network MR analysis.

Results

In stage 1, the univariable MR analysis identified 14 microbiota potentially influencing five different sleep disorders. In stage 2, the results from our observational study validated four of these associations. In stage 3, the network MR analysis revealed that the Negativicutes class and Selenomonadales order might worsen insomnia by increasing pain [mediation: 12.43% (95% CI: 0.47, 24.39%)]. Oxalobacter could raise EDS by disrupting adenosine reuptake [25.39% (1.84, 48.95%)]. Allisonella may elevate OSA risk via obesity promotion [36.88% (17.23, 56.54%)], while the Eubacterium xylanophilum group may lower OSA risk by decreasing smoking behavior [7.70% (0.66, 14.74%)].

Conclusion

Triangulation of evidence from the MR and observational study revealed indirect causal relationships between the microbiota and sleep disorders, offering fresh perspectives on how gut microbiota modulate sleep.

An extract of phase II and III trials on recent developments in managing neuropathic pain syndromes: diabetic peripheral neuropathy, trigeminal neuralgia, and postherpetic neuralgia

INTRODUCTION

Neuropathic pain (NP) conditions involve lesions to the somatosensory nervous system leading to chronic and debilitating pain. Many patients suffering from NP utilize pharmacological treatments with various drugs that seek to reduce pathologic neuronal states. However, many of these drugs show poor efficacy as well as cause significant adverse effects. Because of this, there is a major need for the development of safer and more efficacious drugs to treat NP.

AREAS COVERED

In this review, we analyzed current treatments being developed for a variety of NP conditions. Specifically, we sought drugs in phase II/III clinical trials with indications for NP conditions. Various databases were searched including Google Scholar, PubMed, and clinicaltrials.gov.

EXPERT OPINION

All the mentioned targets for treatments of NP seem to be promising alternatives for existing treatments that often possess poor side effect profiles for patients. However, gene therapy potentially offers the unique ability to inject a plasmid containing growth factors leading to nerve growth and repair. Because of this, gene therapy appears to be the most intriguing new treatment for NP.

Sleep as a prognostic factor in low back pain: a systematic review of prospective cohort studies and secondary analyses of randomized controlled trials

Sleep problems are common in individuals with low back pain (LBP) and sleep restriction seems to be associated with impaired pain processing. Our objective was to investigate whether sleep is associated with future LBP outcomes (i.e. pain intensity, disability, and recovery) in adults. We conducted a systematic review of prospective cohort studies and secondary analyses of randomized controlled trials (registration-PROSPERO CRD42022370781). In December 2022, we searched the MEDLINE, Embase, CINAHL, and PsycINFO databases. Fourteen studies, totaling 19 170 participants were included. Thirteen studies were rated as having high risk of bias (QUIPS tool). We used vote-counting and meta-analysis approaches to synthesize the data. We found associations between baseline sleep with future pain intensity, recovery, and between changes in sleep with changes in pain intensity, changes in disability, and recovery. We further synthesized outcomes as "overall LBP improvement" outcomes. Baseline poor sleep was moderately associated with non-improvement in LBP in the long-very long term (OR 1.55, 95% CI: 1.39 to 1.73; three studies providing unadjusted effect sizes), and non-improvement in sleep was largely associated with non-improvement in LBP in the short-moderate term (OR 3.45, 95% CI: 2.54 to 4.69; four studies providing unadjusted effect sizes). We found no association between baseline sleep with future disability and overall LBP improvement in the short-moderate term. Therefore, sleep may be a prognostic factor for pain intensity and recovery from LBP. All findings were supported by low to very low-quality evidence. Better-conducted studies are needed to strengthen our certainty about the evidence.

Cross-cultural adaption, validity, and reliability of the Japanese version of the Central Aspects of Pain in the Knee (CAP-Knee-J) questionnaire in patients with knee pain: a validation study

BACKGROUND

Knee pain is a prominent concern among older individuals, influenced by the central nervous system. This study aimed to translate the Central Aspects of Pain in the Knee (CAP-Knee) questionnaire into Japanese and investigate its reliability and validity in older Japanese individuals with knee pain.

METHODS

Using a forward-backward method, CAP-Knee was translated into Japanese, and data from 110 patients at an orthopedic clinic were analyzed. The Japanese version (CAP-Knee-J) was evaluated regarding pain intensity during walking, central sensitization inventory, and pain catastrophizing scale. Statistical analyses confirmed internal validity and test-retest reliability. Concurrent validity was assessed through a single correlation analysis between CAP-Knee-J and the aforementioned measures. Exploratory factor analysis was employed on each CAP-Knee-J item to examine structural validity.

RESULTS

CAP-Knee-J showed good internal consistency (Cronbach's α = 0.86) and excellent test-retest reliability (intraclass correlation coefficient = 0.77). It correlated significantly with pain intensity while walking, central sensitization inventory scores, and pain catastrophizing scale scores. Exploratory factor analysis produced a three-factor model.

CONCLUSIONS

CAP-Knee-J is a reliable and valid questionnaire for assessing central pain mechanisms specific to knee pain in older Japanese individuals, with moderate correlations with the CSI and weak with the PCS, thus indicating construct validity. This study supports the development of effective knee pain treatments and prognosis predictions.

The Impact of Sleep Disturbances on Endogenous Pain Modulation: A Systematic Review and Meta-Analysis

The bidirectional relationship between sleep and pain problems has been extensively demonstrated but despite all the accumulating evidence, their shared mechanisms are currently not fully understood. This review examined the association between sleep disturbances, defined as a broad array of sleep-related outcomes (eg, poor quality, short duration, insomnia), and endogenous pain modulation (EPM) in healthy and clinical populations. Our search yielded 6,151 references, and 37 studies met the eligibility criteria. Qualitative results showed mixed findings regarding the association between sleep disturbances and temporal summation of pain (TSP) and conditioned pain modulation (CPM), with poor sleep more commonly associated with decreased pain inhibition in both populations. Quantitative results indicated that such associations were not statistically significant, neither in healthy populations when EPM outcomes were assessed for changes pre-/post-sleep intervention (TSP: .31 [95%CI: -.30 to .92]; P = .321; CPM: .40 [95%CI: -.06 to .85] P = .088) nor in clinical populations when such association was assessed via correlation (TSP: -.00 [95%CI: -.22 to .21] P = .970; CPM: .12 [95%CI: -.05 to .29]; P = .181). For studies that reported results by sex, meta-analysis showed that experimental sleep disturbances impaired pain inhibition in females (1.43 [95%CI: .98-1.88]; P < .001) but not in males (-.30 [95%CI: -2.69 to 1.60]; P = .760). Only one study investigating the association between sleep disturbances and offset analgesia was identified, while no studies assessing spatial summation of pain were found. Overall, this review provides a comprehensive overview of the association between sleep disturbances and EPM function, emphasizing the need for further investigation to clarify specific mechanisms and phenotypic subtypes. PERSPECTIVE: This review shines a light on the association between sleep disturbances and endogenous pain modulation function. Qualitatively, we found a frequent association between reduced sleep quality and impaired pain inhibition. However, quantitatively such an association was not corroborated. Sex-specific effects were observed, with females presenting sleep-related impaired pain inhibition but not males.

Validity and Reliability of the Greek Version of Pittsburgh Sleep Quality Index in Chronic Non-Specific Low Back Pain Patients

The purpose of this study was to investigate psychometric properties of the Greek translation of Pittsburgh Sleep Quality Index (GR-PSQI) in a Greek chronic non-specific low back pain (CNSLBP) sample, thus, providing insight on its clarity and acceptability as a widely used sleep assessment tool in clinical practice. Asymptomatic volunteers (n = 73) and CNSLBP volunteers (n = 47), participated in the study. For the assessment of construct validity, the known-groups method was used. Thus, all the participants (asymptomatic and CNSLBP) completed the GR-PSQI. For the assessment of concurrent validity, the CNSLBP participants additionally completed the following validated questionnaires for depression, insomnia and sleep quality: Beck Depression Inventory Questionnaire (BDI), Insomnia Severity Index (ISI), and Sleep Quality Numeric Rating Scale (SQNRS). For the assessment of test-retest reliability, the CNSLBP participants completed the GR-PSQI a second time, one week after the first time. The results showed excellent test-retest reliability (ICC = 0.969, SEM = 0.90, SDD = 2.49%) and internal consistency (Cronbach α = 0.985), moderate to good concurrent validity (from r = 0.556 to r = 0.860) among PSQI, BDI, SQNRS, and ISI, as well as excellent construct validity (p = 0.000) between the two groups. The Greek translation of PSQI could be a valuable tool for Greek healthcare professionals in both clinical and research environments.

Comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain: A systematic review with network meta-analysis

This network meta-analysis aimed to estimate the comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain. Seven databases were systematically searched up to February 2023. A random-effects network meta-analysis in a frequentist framework was performed to synthesize continuous data as standardized mean differences (SMD) along with a 95% confidence interval (95% CI). A total of 15,641 records were identified, and 107 randomized controlled trials involving 8,121 participants were included. Of 14 identified interventions, eight were significantly more effective than passive control in improving sleep quality at immediate post-intervention (SMDs = 0.67-0.74), with cognitive behavioral therapy (CBT) being the most effective treatment (SMD = 0.74, 95% CI: 0.45-1.03). Only CBT demonstrated sustained effects at short-term (SMD = 1.56; 95% CI: 0.62-2.49) and mid-term (SMD = 1.23; 95% CI: 0.44-2.03) follow-ups. Furthermore, CBT significantly improved subjective (SMD = 0.64; 95% CI: 0.25-1.03) and objective (SMD = 0.30; 95% CI: 0.01-0.59) sleep efficiency compared with passive control at immediate post-intervention. Our findings support CBT as the first-line treatment for improving sleep in individuals with chronic musculoskeletal pain, given its superior effectiveness across multiple sleep outcomes and its sustainable effects until mid-term follow-up. However, the certainty of evidence for these interventions in improving sleep quality was very low to low.

Personalized Multimodal Lifestyle Intervention as the Best-Evidenced Treatment for Chronic Pain: State-of-the-Art Clinical Perspective

Chronic pain is the most prevalent disease worldwide, leading to substantial disability and socioeconomic burden. Therefore, it can be regarded as a public health disease and major challenge to scientists, clinicians and affected individuals. Behavioral lifestyle factors, such as, physical (in)activity, stress, poor sleep and an unhealthy diet are increasingly recognized as perpetuating factors for chronic pain. Yet, current management options for patients with chronic pain often do not address lifestyle factors in a personalized multimodal fashion. This state-of-the-art clinical perspective aims to address this gap by discussing how clinicians can simultaneously incorporate various lifestyle factors into a personalized multimodal lifestyle intervention for individuals with chronic pain. To do so the available evidence on (multimodal) lifestyle interventions targeting physical (in)activity, stress, sleep and nutritional factors, specifically, was reviewed and synthetized from a clinical point of view. First, advise is provided on how to design a personalized multimodal lifestyle approach for a specific patient. Subsequently, best-evidence recommendations on how to integrate physical (in)activity, stress, sleep and nutritional factors as treatment targets into a personalized multimodal lifestyle approach are outlined. Evidence supporting such a personalized multimodal lifestyle approach is growing, but further studies are needed.

Sleep Efficiency and Sleep Onset Latency in One Saskatchewan First Nation

BACKGROUND

Sleep efficiency and sleep onset latency are two measures that can be used to assess sleep quality. Factors that are related to sleep quality include age, sex, sociodemographic factors, and physical and mental health status. This study examines factors related to sleep efficiency and sleep onset latency in one First Nation in Saskatchewan, Canada.

METHODS

A baseline survey of the First Nations Sleep Health project was completed between 2018 and 2019 in collaboration with two Cree First Nations. One-night actigraphy evaluations were completed within one of the two First Nations. Objective actigraphy evaluations included sleep efficiency and sleep onset latency. A total of 167 individuals participated, and of these, 156 observations were available for analysis. Statistical analysis was conducted using logistic and linear regression models.

RESULTS

More females (61%) than males participated in the actigraphy study, with the mean age being higher for females (39.6 years) than males (35.0 years). The mean sleep efficiency was 83.38%, and the mean sleep onset latency was 20.74 (SD = 27.25) minutes. Age, chronic pain, ever having high blood pressure, and smoking inside the house were associated with an increased risk of poor sleep efficiency in the multiple logistic regression model. Age, chronic pain, ever having anxiety, heart-related illness, and smoking inside the house were associated with longer sleep onset latency in the multiple linear regression model.

CONCLUSIONS

Sleep efficiency and sleep onset latency were associated with physical and environmental factors in this First Nation.

Mediation of the Association Between Physical Exercise and Depressive/Anxiety Symptoms by Pain and Sleep Problems Among Older Adults

In this study, based on the 2022 National Health and Aging Trend Study (N = 5,593, age 65+), we examined direct associations between moderate and vigorous physical exercise (PE) and depressive/anxiety symptoms as well as bothersome pain and sleep problems. We then examined if the association between PE and depressive/anxiety symptoms would be partially mediated by the effects of PE on bothersome pain and sleep problems. Results from a path model showed that controlling for sociodemographic and health statuses, PE was negatively associated with depressive/anxiety symptoms and bothersome pain, but it was not significantly associated with sleep problems. The mediation analysis showed that 10% of the total effects of PE on depressive/anxiety symptoms was indirect effects of PE on bothersome pain. This study is important as it examined the associations among PE, pain, sleep, and depression/anxiety in community-dwelling older adults in their natural environments. Healthcare and social service providers for older adults need to emphasize the importance and benefits of PE for older adults' physical and mental health. Easy access to venues for PE is also important.

Effects of sleep quality on pain, cognitive factors, central sensitization, and quality of life in patients with chronic low back pain

BACKGROUND

Sleep quality in patients with chronic low back pain (CLBP) may affect quality of life (QoL), possibly due to worsening pain, central sensitization (CS), and cognitive factors. However, causal relationship among the factors has not been confirmed yet.

OBJECTIVE

The purpose of this study was to test the hypothesis that sleep quality in patients with CLBP is attributable to pain, cognitive factors, and CS, and influences QoL, by structural covariance analysis.

METHODS

This is a cross-sectional study. Participants were recruited from six health care facilities and 101 patients with CLBP were included. Structural covariance analysis assessed the fit of data to the model using goodness of fit index (GFI), adjusted goodness of fit index (AGFI), comparative fit index (CFI), and mean squared approximation error (RMSEA).

RESULTS

The structural covariance analysis showed that the goodness-of-fit indices were high (GFI = 0.993, AGFI = 0.964, CFI = 1.00, RMSEA < 0.01). Sleep quality was not directly influenced by QoL but rather by CS and cognitive factors.

CONCLUSION

This study suggests that sleep quality in patients with CLBP is indirectly mediated through multiple pathways, including cognitive factors and CS, which may influence QoL.

Are physical therapy interventions effective in improving sleep in people with chronic pain? A systematic review and multivariate meta-analysis

Chronic pain exerts an enormous personal and economic burden, with sleep disturbances being one of the most reported problems by adults with chronic pain. The aim of this study was to analyse whether different physical therapy interventions could lead to improvements in sleep quality and pain intensity in individuals with chronic pain, as well as if there is any association. A systematic review and a univariate and multivariate meta-analysis were carried out according to the PRISMA guidelines. A search in PubMed, Scopus and Web of Science databases was performed. Six randomised controlled trials were included in the review and four of them were included in the meta-analysis; all of them with a moderate to high methodological quality. Data from adult participants with chronic pain after different physical therapy interventions was extracted. For the meta-analysis, the Insomnia Severity Index and the Numerical Rating Scale were considered. Results from the qualitative and quantitative analysis showed that most of the physical therapy interventions included had higher improvements in the intervention group than in the control group, although the effect size was not statistically significant (univariate for sleep quality: -0.08 [-0.34, 0.18], p = 0.46; univariate for pain intensity: -0.47 [-1.24, 0.30], p = 0.18; multivariate for both outcomes: -0.27). More studies are still needed to determine which physical therapy interventions are effective to improve sleep in people with chronic pain and if there are patients with specific characteristics who may benefit more than others.

Insomnia is associated with symptoms of central sensitization in patients with painful temporomandibular disorders

BACKGROUND

Central sensitization (CS) and temporomandibular disorder (TMD) are both associated with insomnia. Therefore, the authors aimed to investigate whether insomnia was associated with more symptoms of CS in patients with TMD.

METHODS

In 82 volunteers with TMD, insomnia was clinically assessed, allowing sample stratification according to its presence. The Central Sensitization Inventory questionnaire was self-applied to assess the clinical symptoms of CS.

RESULTS

Participants with insomnia had significantly higher mean (SD) scores of CS according to the Central Sensitization Inventory than participants without insomnia (43.10 [12.57] vs 26.59 [13.66]; P = < .001).

CONCLUSIONS

Insomnia was associated with higher scores of CS symptoms in patients with TMD.

PRACTICAL IMPLICATIONS

Insomnia influences TMD as well as its relationship with CS, and, therefore, it is critical to the clinical management of TMD.

Telerehabilitation for persistent Pelvic Girdle Pain within a biopsychosocial framework - A case report

BACKGROUND

Persistent pregnancy-related pelvic girdle pain (PGP) and the resulting consequences may considerably influence a woman's quality of life. The complexity of this condition requires a whole-person centered approach. In response to COVID-19 outbreak, telerehabilitation has emerged as a promising alternative to traditional in-person visits.

PURPOSE

The aim of this report was to present the potential of telerehabilitation for persistent postpartum PGP within the biopsychosocial framework.

CASE DESCRIPTION

A 26-year-old female presented with persistent pregnancy-related PGP of 8 months duration after her first vaginal delivery. The video-consults were performed using telerehabilitation platform. The patient received six telerehabilitation consults of 45 min duration over five weeks. Assessment of physical and psychosocial factors, cognitively focused strategies including pain neurophysiology education, sensory-motor remapping exercises, and graded increase of activity were administered. Rehabilitation was divided into the following phases: assessment, desensitization, graded exposure, and supported independence.

OUTCOMES

The Pelvic Girdle Questionnaire (PGQ) score was significantly reduced from 72.2 during the assessment to 15.3 at discharge. This change was significantly more substantial than the minimal clinically important change estimated for the PGQ.

CONCLUSION

Physiotherapists can utilize telerehabilitation to assist them with enacting appropriate care measures for persistent PGP within a biopsychosocial framework.

Precision management of post-COVID pain: An evidence and clinical-based approach

Background Pain after a SARS-CoV-2 acute infection (post-COVID pain) is becoming a new healthcare emergency but remains underestimated and most likely undertreated due to a lack of recognition of the phenomenon and knowledge of the underlying pain mechanisms. Evidence supporting any particular treatment approach for the management of post-COVID pain is lacking. Large variability in the patient response to any standard pain treatments is clinically observed, which has led to calls for a personalized, tailored approach to treating patients with chronic post-COVID pain (i.e. 'precision pain medicine'). Applying the global concerted action towards precision medicine to post-COVID pain could help guide clinical decision-making and aid in more effective treatments. Methods The current position paper discusses factors to be considered by clinicians for managing post-COVID pain ranging from identification of the pain phenotype to genetic consideration. Results The ability of clinicians to phenotype post-COVID pain into nociceptive, neuropathic, nociplastic or mixed type is suggested as the first step to better planification of a treatment programme. Further, the consideration of other factors, such as gender, comorbidities, treatments received at the acute phase of infection for onset-associated COVID-19 symptoms, factors during hospitalization or the presence of emotional disturbances should be implemented into a treatment programme. Conclusions Accordingly, considering these factors, management of post-COVID pain should include multimodal pharmacological and non-pharmacological modalities targeting emotional/cognitive aspects (i.e. psychological and/or coping strategies), central sensitization-associated mechanisms (i.e. pain neuroscience education), exercise programmes as well as lifestyle interventions (e.g. nutritional support and sleep management). SIGNIFICANCE: This position paper presents an evidence-based clinical reasoning approach for precision management of post-COVID pain.

Macrophages and microglia in inflammation and neuroinflammation underlying different pain states

Pain is a main symptom in inflammation, and inflammation induces pain via inflammatory mediators acting on nociceptive neurons. Macrophages and microglia are distinct cell types, representing immune cells and glial cells, respectively, but they share similar roles in pain regulation. Macrophages are key regulators of inflammation and pain. Macrophage polarization plays different roles in inducing and resolving pain. Notably, macrophage polarization and phagocytosis can be induced by specialized pro-resolution mediators (SPMs). SPMs also potently inhibit inflammatory and neuropathic pain via immunomodulation and neuromodulation. In this review, we discuss macrophage signaling involved in pain induction and resolution, as well as in maintaining physiological pain. Microglia are macrophage-like cells in the central nervous system (CNS) and drive neuroinflammation and pathological pain in various inflammatory and neurological disorders. Microglia-produced inflammatory cytokines can potently regulate excitatory and inhibitory synaptic transmission as neuromodulators. We also highlight sex differences in macrophage and microglial signaling in inflammatory and neuropathic pain. Thus, targeting macrophage and microglial signaling in distinct locations via pharmacological approaches, including immunotherapies, and non-pharmacological approaches will help to control chronic inflammation and chronic pain.

The Classification of Suspected Predominant Nociplastic Pain in People with Moderate and Severe Haemophilia: A Secondary Exploratory Study

In people with haemophilia (PwH), joint pain is a major comorbidity that is often overlooked and under-treated. It is believed that, to ensure the most successful outcome, pain management should be tailored to the predominant pain phenotype (i.e., nociceptive, neuropathic and nociplastic). The 2021 clinical criteria and grading system for nociplastic pain, established by the International Association for the Study of Pain (IASP), emphasize the necessity of early-stage identification and predominant pain type classification. Consistent with findings in other chronic musculoskeletal pain conditions, studies suggest that a subgroup of PwH suffers from nociplastic pain, i.e., pain arising from altered nociception rather than structural damage, but this has not yet been explored in PwH. This study aimed to identify PwH with "unlikely", "possible" and "probable" nociplastic pain and investigate differences in anthropometric, demographic and clinical characteristics and psychological factors between subgroups of PwH and healthy individuals.: The IASP clinical criteria and grading system were used to classify pain types in adult men with moderate or severe haemophilia recruited from two Belgian haemophilia treatment centres. Statistical analyses were applied to study between-subgroup differences. Of 94 PwH, 80 PwH (85%) were classified with "unlikely" and 14 (15%) with "at least possible" nociplastic pain (including 5 PwH (5%) with "possible" and 9 PwH (10%) with "probable" nociplastic pain). PwH in both the "unlikely" and "at least possible" nociplastic pain groups showed significantly higher levels of unhelpful psychological factors compared to healthy individuals. Additionally, age may partially account for the observed differences in body height and psychological factors. Larger sample sizes may be needed to detect more subtle between-group differences. study confirmed the presence of nociplastic pain in haemophilia, categorising a notable subgroup as individuals who experience at least possible nociplastic pain. These exploratory insights may provide a starting point for future studies and the development of more effective and tailored pain management.

The bidirectional association between chronic musculoskeletal pain and sleep-related problems: a systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis synthesizes the evidence on prospective bidirectional associations between sleep-related problems (SRP) and chronic musculoskeletal pain (CMP).

METHODS

A literature search for cohort studies available in the PubMed, Scopus, Web of Science, PsycINFO and Cochrane Library databases as of 19 July 2022 was performed. Pooled odds ratios and effect sizes were calculated through random effects meta-analysis. Subgroup and meta-regression analyses were performed to explore differences by follow-up time, proportion of each sex and mean age. The Meta-analysis Of Observational Studies in Epidemiology guidelines were strictly followed.

RESULTS

Twenty studies with a total of 208 190 adults (aged 34.4-71.7 years) were included, with 17 of them being used in the meta-analysis. Individuals with SRP at baseline had a 1.79-fold higher incidence (odds ratio [OR] = 1.79; 95% CI: 1.55, 2.08; I2 = 84.7%; P < 0.001) and a 2.04-fold higher persistence (OR = 2.04; 95% CI: 1.42, 2.94; I2 = 88.5%; P < 0.005) of CMP than those without SRP. In the subgroup analysis of the association between SRP and CMP, the longer the follow-up time of the studies, the higher the heterogeneity between them. In the corresponding meta-regression, no significant effect was observed for follow-up time, sex proportion or age. Individuals with CMP at baseline had a 2.02-fold higher incidence of SRP (OR = 2.02; 95% CI: 1.62, 2.53; I2 = 90.0%; P < 0.001) than those without CMP.

CONCLUSION

This study provides robust evidence concerning the longitudinal association between SRP and incidence-persistence of CMP in adults. In addition, the available prospective studies support the existence of a bidirectional relationship between CMP and SRP.

PROSPERO REGISTRATION NUMBER

CRD42020212360.

The relationship between central sensitization and disease activity, quality of life, and sleep quality among patients with axial spondyloarthritis

BACKGROUND

Central sensitization (CS) has been held responsible in previous studies for persistent pain and persistently high disease activity in axial spondyloarthritis (axSpA). Sleep disturbance is also regarded as an important problem for patients with axSpA.

AIMS

This study determines the CS levels of patients with axSpA compared to healthy controls (HC) and investigates its relationship with disease activity, quality of life (QoL), and sleep quality.

METHODS

Eighty-two patients with axSpA (group 1: mean age 38.83 ± 10.11 (76.8%male)) and 40 healthy volunteers (group2: mean age 38.58 ± 7.48 (77.5%male)) were included in this cross-sectional observational study. Evaluation parameters were visual analog scale (VAS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), Short Form-36 (SF-36), Central Sensitization Inventory (CSI), and Pittsburgh Sleep Quality Index (PSQI). Also, participants were divided into subgroups as CSI < 40 and CSI ≥ 40. Groups were compared to themselves. A correlation between the patients' CSI scores and other evaluation parameters was examined.

RESULTS

CS rates were 45.1% and 7.5% for axSpA and HC, respectively (p < 0,001). The frequency of severe forms of CS was higher in patients with axSpA than in the healthy controls (p < 0.05). AxSpA patients with CS exhibited significantly higher pain, MASES, BASDAI, ASDAS-CRP, and PSQI scores than axSpA patients without CS (p < 0.05). A close relationship between CS severity and the female gender, pain, disease activity, sleep quality, and QoL was found among axSpA patients.

CONCLUSIONS

Clinical CS is common among axSpA patients. CS adversely affects disease activity, pain, sleep quality, and QoL of axSpA patients. CS should be considered when planning axSpA treatment.

A bidirectional study of the association between insomnia, high-sensitivity C-reactive protein, and comorbid low back pain and lower limb pain

OBJECTIVES

To examine the possible bidirectional association between insomnia and comorbid chronic low back pain (LBP) and lower limb pain and to explore whether high-sensitivity C-reactive protein (hsCRP) amplifies these associations.

METHODS

We calculated adjusted risk ratios (RR) with 95% confidence intervals (CI) for the development of insomnia and mild-to-severe chronic LBP and lower limb pain at 11 years follow-up in participants aged ≥32 years and with hsCRP ≤10 mg/L at baseline in 2007-2008: 3,714 without chronic LBP or lower limb pain (sample 1) and 7,892 without insomnia (sample 2).

RESULTS

Compared to participants without chronic pain, participants with comorbid chronic LBP and lower limb pain had a RR of insomnia of 1.37 (95% CI 1.12-1.66). Compared with participants without insomnia, participants with insomnia did not have an increased risk of comorbid chronic LBP and lower limb pain (RR: 1.06, 95% CI 0.76-1.46); however, participants with insomnia had a RR of chronic LBP of 1.20 (95% CI 1.02-1.42). There was no strong amplifying effect of elevated hsCRP (3.00-10.0 mg/L) on these associations.

CONCLUSIONS

These findings suggest that elevated hsCRP does not amplify the associations between insomnia and mild-to-severe chronic LBP and lower limb pain. Further research using data on the temporal relation between insomnia, chronic pain, and inflammatory responses are required to fully understand the causal pathways.

Causal association of sleep disturbances and low back pain: A bidirectional two-sample Mendelian randomization study

BACKGROUND

Previous observational studies have shown that low back pain (LBP) often coexists with sleep disturbances, however, the causal relationship remains unclear. In the present study, the causal relationship between sleep disturbances and LBP was investigated and the importance of sleep improvement in the comprehensive management of LBP was emphasized.

METHODS

Genetic variants were extracted as instrumental variables (IVs) from the genome-wide association study (GWAS) of insomnia, sleep duration, short sleep duration, long sleep duration, and daytime sleepiness. Information regarding genetic variants in LBP was selected from a GWAS dataset and included 13,178 cases and 164,682 controls. MR-Egger, weighted median, inverse-variance weighted (IVW), penalized weighted median, and maximum likelihood (ML) were applied to assess the causal effects. Cochran's Q test and MR-Egger intercept were performed to estimate the heterogeneity and horizontal pleiotropy, respectively. Outliers were identified and eliminated based on MR-PRESSO analysis to reduce the effect of horizontal pleiotropy on the results. Removing each genetic variant using the leave-one-out analysis can help evaluate the stability of results. Finally, the reverse causal inference involving five sleep traits was implemented.

RESULTS

A causal relationship was observed between insomnia-LBP (OR = 1.954, 95% CI: 1.119-3.411), LBP-daytime sleepiness (OR = 1.011, 95% CI: 1.004-1.017), and LBP-insomnia (OR = 1.015, 95% CI: 1.004-1.026), however, the results of bidirectional MR analysis between other sleep traits and LBP were negative. The results of most heterogeneity tests were stable and specific evidence was not found to support the disturbance of horizontal multiplicity. Only one outlier was identified based on MR-PRESSO analysis.

CONCLUSION

The main results of our research showed a potential bidirectional causal association of genetically predicted insomnia with LBP. Sleep improvement may be important in comprehensive management of LBP.

Differences in pain, disability, and psychological function in low back pain patients with and without anxiety

Objectives: Non-specific low back pain affects people of all ages and is a leading contributor to disease burden worldwide. Chronic low back pain (LBP) reduces working hours, increases comorbidities, and increases rehabilitation needs. The aim of this study was to evaluate whether there were differences in pain, dysfunction, and psychological factors between two groups. The supplementary demonstrated the relationship between these influencing factors and anxiety.

Methods: A cross-sectional study was designed to analyze the differences in pain, disability, and psychological function in non-specific LBP patients with and without anxiety. In total, 60 subjects were divided into two groups based on self-rated anxiety scores: 30 patients with SAS score ≥50 were in the low back pain with anxiety group, and 30 for the LBP without anxiety group with SAS score &lt;50. The pain intensity was assessed using the Visual Analog Scale; psychological function, using the Pain Anxiety Symptoms Scale, the Tampa Scale for Kinesiophobia, and the Fear Avoidance Beliefs Questionnaire; functional disability, using the Oswestry Disability Index and the Roland–Morris Disability Questionnaire; quality of life using 36-Item Short-Form Health Survey questionnaire; and the quality of sleep using Pittsburgh Sleep Quality Index, and the relationships between variables and anxiety scores were estimated using Spearman correlation analysis.

Results: A total of 60 participants were enrolled after self-rated anxiety was assessed and the full investigation was finished. The analyses showed significant differences of pain intensity (p = 0.034, disability (ODI, p = 0.007; RMDQ, p = 0.012) and psychological function (TSK, p = 0.000; PASS, p = 0.009; FABQ, p = 0.000; SF-36, p = 0.000; and PSQI, p = 0.000) between the two groups. Spearman correlation analysis showed that the anxiety score had significant positive correlations with functional disability (ODI, p = 0.004 and 95% CI = 0.112–0.573; RMDQ, p = 0.003, 95% CI = 0.135–0.586) and psychological function (TSK, p = 0.001, 95% CI = 0.174–0.612), excellent positive correlation with quality of sleep (PASS, p = 0.025, 95% CI = 0.031–0.512), and strongly negative correlations with the quality of life (SF-36, p = 0.000, 95% CI = 0.761–0.433).

Conclusion: We recognized that anxiety in low back pain patients was mainly due to interaction with the intensity of pain, disability level, and a mass of psychological function. The future research direction could be to alleviate the anxiety on the comprehensive efficacy of patients with low back pain.

Role of Occupational Therapy in Pain Management

This new position statement from the American Occupational Therapy Association (AOTA) describes occupational therapy's role in pain management. AOTA asserts that occupational therapy practitioners are distinctly prepared to work independently and to contribute to interprofessional teams in the treatment of pain. Practitioners strive to ensure active engagement in meaningful occupations for clients at risk for and affected by pain.

Role of Occupational Therapy in Pain Management

The American Occupational Therapy Association (AOTA) asserts that occupational therapists and occupational therapy assistants, collectively referred to as occupational therapy practitioners (AOTA, 2020b), are distinctly prepared to work independently and to contribute to interprofessional teams in the treatment of pain. Occupational therapy practitioners work to ensure active engagement in meaningful occupations for "persons, groups, or populations (i.e., the client)" (AOTA, 2020b, p. 1) at risk for and affected by pain.

Non-invasive brain neuromodulation techniques for chronic low back pain

Structural and functional changes of the brain occur in many chronic pain conditions, including chronic low back pain (CLBP), and these brain abnormalities can be reversed by effective treatment. Research on the clinical applications of non-invasive brain neuromodulation (NIBS) techniques for chronic pain is increasing. Unfortunately, little is known about the effectiveness of NIBS on CLBP, which limits its application in clinical pain management. Therefore, we summarized the effectiveness and limitations of NIBS techniques on CLBP management and described the effects and mechanisms of NIBS approaches on CLBP in this review. Overall, NIBS may be effective for the treatment of CLBP. And the analgesic mechanisms of NIBS for CLBP may involve the regulation of pain signal pathway, synaptic plasticity, neuroprotective effect, neuroinflammation modulation, and variations in cerebral blood flow and metabolism. Current NIBS studies for CLBP have limitations, such as small sample size, relative low quality of evidence, and lack of mechanistic studies. Further studies on the effect of NIBS are needed, especially randomized controlled trials with high quality and large sample size.

Associations between insomnia and central sensitization in cancer survivors undergoing opioid therapy for chronic cancer pain: A STROBE-compliant prospective cohort study

Several risk factors for insomnia in cancer patients have been recognized, including chronic pain and treatment with opioid. Although associations between insomnia and central sensitization were previously reported in patients with chronic non-cancer pain, those have not been elucidated among cancer survivors undergoing opioid therapy for chronic cancer pain. To investigate the associations between insomnia and central sensitization among cancer survivors undergoing opioid therapy for chronic cancer pain, consecutive patients undergoing chemotherapy with chronic cancer pain under opioid therapy on an outpatient basis were enrolled from September 2019 to August 2020 and answered questions from the Athens Insomnia Scale (AIS) for assessing insomnia. Pain characteristics, including pain intensity, neuropathic pain, central sensitization assessed using the central sensitization inventory (CSI), opioid use disorder, and pain-related psychological symptoms were also examined. Uni- and multivariate regression analyses were performed to elucidate correlations between the AIS score and these pain characteristics. Of 44 enrolled patients, 20 patients completed to answer all questions. Insomnia was identified in 9 patients (45%). Although AIS scores showed no significant associations with pain intensity, neuropathic pain, opioid use disorder, or psychological symptoms, multivariate regression analysis revealed that CSI scores showed a positive relationship with AIS scores (P = .004). Discrimination was assessed using linear regression analysis which confirmed a significant association between the AIS and CSI scores (P = .002). Insomnia appears to be associated with central sensitization in cancer survivors with chronic cancer pain under opioid therapy.

Development of a nomogram prediction model for depression in patients with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an inflammatory autoimmune disease with depression as one of its most common symptoms. The aim of this study is to establish a nomogram prediction model to assess the occurrence of depression in patients with SLE. Based on the Hospital Anxiety and Depression Scale cutoff of 8, 341 patients with SLE, recruited between June 2017 and December 2019, were divided into depressive and non-depressive groups. Data on socio-demographic characteristics, medical history, sociopsychological factors, and other risk factors were collected. Between-group differences in clinical characteristics were assessed with depression as the dependent variable and the variables selected by logistic multiple regression as predictors. The model was established using R language. Marital status, education, social support, coping, and anxiety predicted depression (p < 0.05). The nomogram prediction model showed that the risk rate was from 0.01 to 0.80, and the receiver operating characteristic curve analysis showed that the area under the curve was 0.891 (p < 0.001). The calibration curve can intuitively show that the probability of depression predicted by the nomogram model is consistent with the actual comparison. The designed nomogram provides a highly predictive assessment of depression in patients with SLE, facilitating more comprehensive depression evaluation in usual clinical care.

Prevalence of chronic pelvic pain and primary dysmenorrhea in women of reproductive age in Ecuador

Background

Chronic pelvic pain (CPP) and primary dysmenorrhoea are debilitating conditions that can impair the quality of life of affected women. These conditions are frequently neglected, delaying proper diagnosis and healthcare provision. This study aimed to estimate the prevalence of CPP and primary dysmenorrhoea in Ecuador and identify potential variables associated with their occurrence.

Methods

We conducted a cross-sectional survey in an urban neighbourhood of Quito, the capital of Ecuador. A total of 2397 participants of 14–49 years of age were included. The data were collected through questionnaires administered by trained interviewers.The crude and adjusted prevalence ratios were calculated using a log-binomial regression model. The correlation between pain intensity catastrophising of symptoms were statistically analysed.

Results

The prevalence of CPP and primary dysmenorrhoea was 9.8% and 8.9%, respectively. Irritative urinary symptoms, primary dysmenorrhoea, and underlying mental disorders were associated with CPP, while smoking, irritable bowel syndrome, sleep disturbance, dyspareunia, and mental disorders were associated with primary dysmenorrhoea.

Conclusions

The prevalence of CPP and primary dysmenorrhoea in Ecuador was similar to that in other Latin American countries. Primary dysmenorrhoea is a risk factor of CPP, and less than a quarter of women are undergoing treatment for the condition. Our findings reinforce the importance of healthcare interventions in anticipating the diagnosis of these conditions in women of reproductive age.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01948-y.

Promoting sleep in low-income older adults with disabilities: Comparing CAPABLE with a social engagement control

Sleep plays a vital role in older adults' health. The Community Aging in Place-Advancing Better Living for Elders (CAPABLE) trial, conducted in Maryland between 2012 and 2016, is a 5-month biobehavioral environmental intervention study to reduce functional disabilities in 300 low-income older adults. Individual and environmental factors impacting sleep were addressed in CAPABLE. This secondary data analysis was to test the preliminary effect of CAPABLE on actigraph-measured sleep, compared with a social engagement control in 73 CAPABLE participants with pretest-posttest actigraph data. Participants in this analysis were aged 75.8±7.5 years; 86.3% of them were females and 84.9% were Black/African Americans. Both CAPABLE intervention and social engagement control improved sleep efficiency and reduced sleep onset latency. The effect of CAPABLE on sleep was comparable to social engagement. These findings underline the importance of promoting physical function and maintaining social activity for sleep in low-income older adults with disabilities.

A simple method for clinical implications of pain; comprehensive geriatric assessment

OBJECTIVE:

The effect of chronic pain on the elderly population is enormous in terms of both human suffering and cost. This study aimed to investigate the factors associated with chronic low back pain in older adults by performing a comprehensive geriatric assessment.

METHODS:

This cross-sectional study included 225 elderly patients admitted to a geriatric outpatient clinic. All participants underwent a comprehensive geriatric assessment, and factors related to chronic low back pain were assessed. Participants were grouped as those with and without chronic pain.

RESULTS:

The mean age of the participants was 72.9±6.9 years, and 149 (66.2%) of them had chronic pain complaints. The number of chronic diseases and medications, depressive symptom scores, and sleep quality scores were higher, and quality of life (European Quality of Life-5 Dimensions index and European Quality of Life-5 Dimensions visual analog scale) and nutritional status scores were lower in the chronic pain group. The pain visual analog scale score had a statistically significant moderate negative correlation with the European Quality of Life-5 Dimensions index (r=-0.440, p=0.000) and European Quality of Life-5 Dimensions visual analog scale (r=-0.398, p=0.000) scores. The male gender was associated with a reduced risk of chronic pain, while poor sleep quality and number of comorbidities were associated with an increased risk of chronic pain (p=0.000, OR 0.20, p=0.021, OR 2.54, and p=0.010, OR 1.40, respectively).

CONCLUSION:

Chronic pain is common and independently associated with poor sleep quality, an increased number of diseases, and female gender. The results of our study may guide pain management in older individuals.

Combining Cognitive Behavioral Therapy for Insomnia and Chronic Spinal Pain Within Physical Therapy: A Practical Guide for the Implementation of an Integrated Approach

Most people who have nonspecific chronic spinal pain (nCSP) report comorbid insomnia. However, in current treatment strategies for nCSP, insomnia is usually not addressed. Considering the bidirectional interaction between pain and sleep and its underlying psychophysiological mechanisms, insomnia may increase the risk of developing adverse physical and psychological health outcomes and should thus no longer be left untreated. As suggested by previous pilot studies, adding cognitive behavioral therapy for insomnia to the contemporary evidence-based biopsychosocial physical therapy approach may also improve pain outcomes in nCSP. This manuscript aims to provide practical guidelines on hybrid physical therapy, including the combination of the following components: (1) pain neuroscience education (eg, to reconceptualize pain) and cognition-targeted exercise therapy (eg, graded exposure to functional daily life movements), and (2) cognitive behavioral therapy for insomnia (sleep psychoeducation, behavioral and cognitive therapy, correction of sleep hygiene, and relaxation therapy) can be deployed for the management of patients who have chronic spinal pain. Impact. Due to the major impact sleep disturbances have on pain and disability, insomnia as a comorbidity should no longer be ignored when treating patients with chronic spinal pain.

Are psychosocial variables, sleep characteristics or central pain processing prognostic factors for outcome following rotator cuff repair? A protocol for a prospective longitudinal cohort study

INTRODUCTION

Prognosis following surgical rotator cuff repair (RCR) is often established through the assessment of non-modifiable biomedical factors such as tear size. This understates the complex nature of recovery following RCR. There is a need to identify modifiable psychosocial and sleep-related variables, and to find out whether changes in central pain processing influence prognosis after RCR. This will improve our knowledge on how to optimise recovery, using a holistic rehabilitation approach.

METHODS AND ANALYSIS

This longitudinal study will analyse 141 participants undergoing usual care for first time RCR. Data will be collected 1-21 days preoperatively (T1), then 11-14 weeks (T2) and 12-14 months (T3) postoperatively. We will use mixed-effects linear regression to assess relationships between potential prognostic factors and our primary and secondary outcome measures-the Western Ontario Rotator Cuff Index; the Constant-Murley Score; the Subjective Shoulder Value; Maximal Pain (Numeric Rating Scale); and Quality of Life (European Quality of Life, 5 dimensions, 5 levels). Potential prognostic factors include: four psychosocial variables; pain catastrophising, perceived stress, injury perceptions and patients' expectations for RCR; sleep; and four factors related to central pain processing (central sensitisation inventory, temporal summation, cold hyperalgesia and pressure pain threshold). Intercorrelations will be assessed to determine the strength of relationships between all potential prognostic indicators.Our aim is to explore whether modifiable psychosocial factors, sleep-related variables and altered central pain processing are associated with outcomes pre-RCR and post-RCR and to identify them as potential prognostic factors.

ETHICS AND DISSEMINATION

The results of the study will be disseminated at conferences such as the European Pain Congress. One or more manuscripts will be published in a peer-reviewed SCI-ranked journal. Findings will be reported in accordance with the STROBE statement and PROGRESS framework. Ethical approval is granted by the Ethical commission of Canton of Zurich, Switzerland, No: ID_2018-02089 TRIAL REGISTRATION NUMBER: NCT04946149.

The Affective Dimension of Pain Appears to Be Determinant within a Pain-Insomnia-Anxiety Pathological Loop in Fibromyalgia: A Case-Control Study

Background: Fibromyalgia (FM) is a chronic pain disease characterized by multiple symptoms whose interactions and implications in the disease pathology are still unclear. This study aimed at investigating how pain, sleep, and mood disorders influence each other in FM, while discriminating between the sensory and affective pain dimensions. Methods: Sixteen female FM patients were evaluated regarding their pain, while they underwent—along with 11 healthy sex- and age-adjusted controls—assessment of mood and sleep disorders. Analysis of variance and correlations were performed in order to assess group differences and investigate the interactions between pain, mood, and sleep descriptors. Results: FM patients reported the typical widespread pain, with similar sensory and affective inputs. Contrary to controls, they displayed moderate anxiety, depression, and insomnia. Affective pain (but neither the sensory pain nor pain intensity) was the only pain indicator that tendentially correlated with anxiety and insomnia, which were mutually associated. An affective pain–insomnia–anxiety loop was thus completed. High ongoing pain strengthened this vicious circle, to which it included depression and sensory pain. Conclusions: Discriminating between the sensory and affective pain components in FM patients disclosed a pathological loop, with a key role of affective pain; high ongoing pain acted as an amplifier of symptoms interaction. This unraveled the interplay between three of most cardinal FM symptoms; these results contribute to better understand FM determinants and pathology and could help in orienting therapeutic strategies.

Distress and Sensitization as Main Mediators of Severity in Women with Fibromyalgia: A Structural Equation Model

We aimed to explore a path model identified using a structural equation model (SEM) which best explains the multivariate contributions of sensitization, sensitivity, and emotional variables to clinical severity in women with FMS. Pain features, the Central Sensitization Inventory (CSI), painDETECT, S-LANSS, the Hospital Anxiety and Depression Scale (HADS), the Pittsburgh Sleep Quality Index (PSQI), the Pain Catastrophizing Scale (PCS), the Pain Vigilance and Awareness Questionnaire (PVAQ), the 11-item Tampa Scale for Kinesiophobia (TSK-11), and pressure pain thresholds (PPTs) were collected from 113 women with FMS. Four latent variables were created: severity (clinical pain features), sensitivity (PPTs), sensitization (S-LANSS, CSI, painDETECT), and distress (HADS-A, HADS-D, PCS, PVAQ, TSK-11). Data fit for the measurement model were considered excellent (RMSEA = 0.043, CFI = 0.966, SRMR = 0.067, and NNFI = 0.960). Distress had a significant relationship with the mediators of sleep (β = 0.452, p = 0.031) and sensitization (β = 0.618, p = 0.001). The only mediator with a significant effect (β = 1.113, p < 0.001) on severity was sensitization. A significant indirect effect of sensitization (β = 0.687, p = 0.001) that explained the relationship between distress and severity was also identified. The proposed model suggests that distress and sensitization, together with poor sleep, have a complex mediating effect on severity in women with FMS. The identified path model can be leveraged in clinical trials investigating treatment approaches for FMS.

The Key Role of Lifestyle Factors in Perpetuating Chronic Pain: Towards Precision Pain Medicine

Chronic pain has a massive personal and socioeconomic impact and remains a challenge for many clinicians around the world [...].

Pain Science Education Plus Exercise Therapy in Chronic Nonspecific Spinal Pain: A Systematic Review and Meta-analyses of Randomized Clinical Trials

Exercise therapy and education are recommended from several guidelines for managing symptoms in chronic nonspecific spinal pain (CNSP) patients. However, no systematic reviews have previously analyzed the effectiveness of pain science education (PSE) plus exercise therapy for managing CNSP related symptoms. Systematic searches were conducted on 10 databases looking for randomized control trials (RCTs) aimed to evaluate the effectiveness on pain, disability, kinesiophobia, and catastrophizing. Data were analyzed using random-effects meta-analyses and studies were appraised using the Cochrane ROB tool and GRADE. A total of eight RCTs (n = 622) were included in the qualitative-analysis and five were selected for meta-analysis. PSE plus exercise therapy showed improvements in pain (5RCTs: short-term: SMD: -0.53 [-0.86,-0.2]; 4RCTs: intermediate-term: SMD: -0.57 [-1.01,-0.14]; low quality), disability (4RCTs: short-term: SMD: -0.24 [-0.53,0.05]; 4RCTs: intermediate-term: SMD: -0.93 [-1.08,-0.03]; low-to-very-low quality), kinesiophobia (3RCTs: short-term: SMD: -0.7 [-1.51,0.11]; 4RCTs: intermediate-term: SMD: -0.93 [-1.57,-0.30]; moderate-to-very-low quality), and catastrophizing (2RCTs: short-term: MD: -3.26 points [-6.15,-0.37]; 3RCTs: intermediate-term: MD: -4.94 points [-8.08,-1.81]; low-to-very-low quality) compared to exercise alone. A qualitative-analysis showed improvements in the experimental group compared to multimodal physiotherapy (1RCT; low-to-very-low quality), whereas no clear benefits were reported compared to PSE alone (1RCT; very-low quality) or no intervention (1RCT; very-low quality). There is low to very-low certainty of the evidence suggesting that PSE plus exercise therapy reduces CNSP related-symptoms. PERSPECTIVE: Based on low-quality data from small samples, PSE plus exercise therapy reduces CNSP related symptoms. The evidence requires further investigation due to the limited number of studies with short follow-up periods (CRD42020168968).